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4 Types Of Constipation - Quick Explainer Guide

Researched and Written by:
Richelle Godwin, RDN Richelle Godwin, RDN

When it comes to constipation, the most common type is normal transit constipation. However, in other cases there are rare but specific subtypes of constipation. These types are taken into consideration when constipation remains unresponsive to simple remedies and treatments, which we will explain later on in this guide. Let's go!

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Table of Contents

    Primary CC has four broad, and overlapping, subtypes:

    1. Normal transit constipation (most common)
    2. Slow transit constipation (STC)
    3. Evacuation disorders (EDs)
    4. Mixed type CC (6)

    And we are here to break them down for you from what it is, to its differentiating pathophysiology, and diagnosis criteria.

  • Normal Transit Constipation:

  • What is it: 

    • Most common type of CC
    • Characterized by muscles in the colon still functioning properly (not too fast or too slow) and bowel movements are at the right speed but still, your stool may be too hard or difficult to pass. 

    Pathophysiology 

    • Perceived difficulties with defecation

    Diagnosis

    • Rome III criteria 

  • Slow Transit Constipation:

  • What is it: 

    • Characterized by reduced motility, delayed movement, of the stool through the large intestines due to an underlying dysfunction and abnormality of the colonic smooth muscle or neuropathy.
    • This slow passage of waste through the large intestines leads to chronic health problems.

    Pathophysiology 

    • Can occur due to dysfunction of:
      • Colonic smooth muscles activity
      • Colocolonic reflexes
      • Neurotransmitters
      • Colonic pacemaker cell activity
    • Decreased overall colonic motor activity
    • Imparied or absent gastrocolonic responses 
    • Decreased or absent sleep-wake motor activity
    • Absent or abnormal number, amplitude, and velocity of high-amplitude propagated
    • Loss of interstitial cells of Cajal
    • Loss of enteric and cholinergic neurons (16)

    Diagnosis

    • No established criteria exists for its diagnosis

  • Pelvic Floor / Evacuation Disorders

  • What is it: 

    • Also known as dyssynergic defecation
    • Characterized by the inability to correctly relax and coordinate the abdominal and anorectal muscles (pelvic floor muscles) to have a bowel movement. In other words, when everything is moving normal, at the normal pace through the large intestine, but have an inability or difficulty with stool evacuation from rectum with the final “push” for a BM (15).
    • The feeling that you may still ‘need to go,’ resulting in constipation.


    8 phenotypes of pelvic floor disorders have been recognized based on high resolution of manometric patterns, however only 4 subtypes have been described:

    • Type I: adequate rectal push effort with paradoxical anal sphincter contraction
    • Type II: inadequate rectal push effort with paradoxical anal sphincter contraction
    • Type III: adequate rectal push effort but inadequate relaxation (<20%) of anal sphincter pressure
    • Type IV: inadequate rectal push effort and also inadequate relaxation (<20%) of anal sphincter pressure (15)

    Pathophysiology 

    • ⅔ rds of patients acquire pelvic floor disorders during adulthood and the remainder have had it since childhood (15). In this case, it's likely the result of problematic childhood toilet habits. (LYG) 
    • Inability to coordinate abdominal, rectoanal and pelvic floor muscles during defecation due to inadequate rectal and/or abdominal propulsive force, impaired anal relaxation (20% relaxation of basal resting pressure) or increased anal outlet resistance from paradoxical external anal sphincter or puborectalis contraction (15). 
    • Pelvic floor disorders can be associated with a weak pelvic floor, rectocele, excessive perineal descent or solitary rectal ulcer syndrome (15). 
      • Associated with delayed gastric emptying in 32% of individuals (15)
      • Associated with rectal hyposensitivity in ⅔ rds of individuals (15)
    • Structural abnormalities
        • Rectal prolapse
        • Rectal mucosal intussusception 
        • Solitary rectal ulcer
        • Rectocele - a collapse of the intestinal wall into the vagina (LYG)
          • Symptoms: 
            • Feeling like there is something coming down into your vagina (it may feel like you’re sitting on a small ball)
            • Feeling or seeing a bulge in or coming out of your vagina
            • Pressure or pain in your bottom
            • Discomfort or numbness during sex (LYG)
        • Enterocele
        • Descending perineum syndrome
    • Dyssynergic defecation
    • Reduced perception of rectal filling
    • Increased acuity of anorectal angle
    • Failure of anal sphincter relaxation
    • Paradoxical contraction of the anal sphincters
    • Inadequate intrabdominal pressure
    • Prolonged retention of stool in the retum
    • Dysregulation of brain-gut axis with a lack of coordination between abdominal musculature, pelvic floor, and anorectal musculature

    Diagnosis 

      • Requires both symptoms and abnormal physiological tests for its diagnosis
      • Proposed diagnostic criteria for dyssynergic defecation (15):
          • Patients must satisfy the diagnostic bacteria for functional CC (Rome III) and
          • Patients must have dyssynergic pattern of defecation (types I-IV), which is defined as a paradoxical increase in anal sphincter pressure (anal contraction) or less than 20% relaxation of the resting and sphincter pressure or inadequate propulsive forces based on manometry, radiological imaging or EMG.
          • Patients must satisfy one or more of the following criteria:
            • Inability to expel an artificial stool (50ml water-filled balloon) within 1 to 2 minutes.
            • Inability to evacuate or >50% retention of barium during defecography

    • Mixed type (eg slow transit + pelvic floor disorders)

    • What is it: 

      •  Combination of the above symptoms

      Prevalence of CC subtypes

      Of the three primary forms of constipation, Nyam’s study evaluating over 1,000 patients showed 59% had normal colonic transit and normal pelvic floor function, 25% had pelvic floor dysfunction, 13% had STC and 3% had miSTC and pelvic floor dysfunction (9).

      What is the difference between IBS-C vs Chronic Constipation?

      The symptom based criteria for CC with normal transit time, noted above, often overlaps with IBS with constipation (IBS-C).

      Constipation-predominant IBS is typically defined using the Rome III criteria and is characterized by abdominal pain or discomfort associated with infrequent or difficult defecation (15).  Studies show that the brain response to visceral distention or even anticipation of pain is increased in individuals with IBS symptoms (15).

      Therefore, the American College of Gastroenterology CC Task Force emphasizes that the presence of clinically important abdominal discomfort associated with constipation symptoms differentiates a spectrum between IBS-C from CC (4).

      CC patients typically report minimal abdominal bloating or discomfort (4). Unfortunately, IBS-C and normal transit CC is largely based on opinion and in some patients with CC it may be difficult, if not nearly impossible, to make this distinction accurately (4).

      Below are some IBS-C targeted self-assessment questions that may be helpful in distinguishing between the spectrum of IBS-C and CC symptoms.

      IBS-C targeted self-assessment questions:

      1. Is your abdominal pain (or discomfort) relieved by deduction?
      2. At the onset of abdominal pain or discomfort, are your stools looser or harder?
      3. When the abdominal pain (or discomfort) begins, do you have more (or less) frequent stools?

      Our Summary

      • Primary CC has four broad, and overlapping, subtypes:
        • Normal transit constipation (most common)
        • Slow transit constipation (STC)
        • Pelvic Floor or Evacuation disorders (EDs)
        • Mixed type CC
      • Normal Transit Constipation
        • Characterized by muscles in the colon still functioning properly (not too fast or too slow) and bowel movements are at the right speed but still, your stool may be too hard or difficult to pass. 
      • Slow transit Constipation
        • Characterized by reduced motility, delayed movement, of the stool through the large intestines due to an underlying dysfunction and abnormality of the colonic smooth muscle or neuropathy.
      • Pelvic Floor or Evacuation Disorders 
        • Characterized by inability or difficulty to correctly relax and coordinate the abdominal and anorectal muscles (pelvic floor muscles) to have the ‘final push’ for complete stool evacuation from the rectum.
      • Differentiating CC from IBS-C symptoms can be difficult and it's often largely based  on opinion; however, it is emphasized that the presence of clinically important abdominal discomfort and pain associated with constipation symptoms differentiates a spectrum between IBS-C from CC.

      Evidence Based

      An evidence hierarchy is followed to ensure conclusions are formed off of the most up-to-date and well-designed studies available. We aim to reference studies conducted within the past five years when possible.

      • Systematic review or meta-analysis of randomized controlled trials
      • Randomized controlled trials
      • Controlled trials without randomization
      • Case-control (retrospective) and cohort (prospective) studies
      • A systematic review of descriptive, qualitative, or mixed-method studies
      • A single descriptive, qualitative, or mixed-method study
      • Studies without controls, case reports, and case series
      • Animal research
      • In vitro research

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